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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 9,321 e-S�CXkjh,07r CRY/ZIP t4---'r� Z-0Dr L <t',t CROSS STREET /1/ c)✓LJ S/- 1l a Lh�/',��",• 0/ `N,t- PARCEL SIZE /� LAND USE APPLICATION# M OWNERNAMEZ -!'7 ©�/�� /�/W PHONE 5777/i; OWNER ADDRESS �/r1 Cn Y/STATE21P CONTRACTOR PHONE CONTRACTOR ADDRESS a 1-7 CfrY/STATE2IP L SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE(ZIP LICENSE Xt-57 I I C-61 i D-09 ElOther NUMBER NTY_p3 r EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range_ Section_ INTENDED USE Domestic/Private dgation/Agricultural 1. Industrial Water Quality Monitoring ❑ Soil Sampling/Characterization Public Water System n different from Owner: Water System Name ontact ame or one um er TYPE OF WORK ew Well n Replacement Well ❑ Well Alteration/Modification ❑ Other 11 Monitoring Wells) #of wells 11 Soil Boring(s) a of borings Geotechnical #of borings $out-Of-Service Well Ll Out-Of-Service Well Renewal 11 Cross-Connection Repair �71Vew Pum m Re lacement❑ Pu ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method-4-Mud Rotary ❑ Air Rotary ❑ Auger Cable Tool n Push Point Ll Other Proposed Well Depth 23C11 Excavation 1C in diameter ❑ Open Bottom 4ravel Pack/Gravel Size in diameter ❑ Conductor Casing In diameter / Conductor Casing Depth It Well Casing Diameter In Thickness/Gauge/ASTM Sched ❑ Steel >Olasfic ❑ Stainless to I F1Other Grout Seal Depth SO ft Neat Cement(94 Ib bag/5-10 gal water) hand Cement / , sack mixl7 gal water 1 Bentonite(20%solids) Other Grout Placement Method 4tPumped - Free Fall r I Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller Pump Contra ❑ Other LI Concrete Pedestal Dimensions:Widthctor ft Length ft Thick - v. in ❑ Christy Box ❑ Stove Pipe PUMP ubmersible❑ Turbine H Other HP= Pump Set ft Standing Water Level it IHEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. M 4 H R ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-7697 SIGNED TITLE to(Aj � L., DATEIL`Lf 1 G �r m Z0 Ulu N N IR0p E T L E L tl DEPARTMENT USE ONLY ,L Application Accepted By .__72� Date z'6�7 b Area T �T n/ Employee ID# s Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PESC Received Check Amount Date Permit/ Invoice# Well ID# Codes in BY s Remitted Service Request# 8 617 It G462- 1)_M, 3W. rd,� 38a pSo 2-36,,-R 7 L EHD 43.06 WELL/PUMP PERMIT 4/30/12